A postsurgical client has been receiving morphine by patient-controlled analgesia for 2 days. What action by the nurse best addresses potential adverse effects?
administering a stool softener as prescribed
auscultating the client's lung for adventitious sounds
encouraging active range of motion exercises
applying calf compressors as prescribed
The Correct Answer is A
A. Administering a stool softener is essential as opioids like morphine commonly cause constipation, and this proactive measure helps mitigate that adverse effect.
B. While auscultating the lungs is important to monitor respiratory function, it does not specifically address a common adverse effect of morphine.
C. Encouraging active range of motion exercises can help prevent complications from immobility but does not directly address the most common adverse effect of morphine.
D. Applying calf compressors can help prevent deep vein thrombosis, but it is not the most effective action for addressing the specific adverse effects of morphine use.
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Correct Answer is C
Explanation
A. Constricted pupils are not an expected response to isoproterenol, which generally causes dilation of the pupils due to sympathetic stimulation.
B. Warm, dry skin is not a direct indicator of the effectiveness of isoproterenol; it could result from various factors unrelated to the medication's action.
C. Increased heart rate indicates that isoproterenol, which is a beta-agonist, is effectively stimulating the beta-adrenergic receptors, leading to increased cardiac output and heart rate.
D. Decreased urine output is not a sign of effectiveness and could indicate adverse effects such as reduced renal perfusion.
Correct Answer is A
Explanation
A. Blood pressure is correct because both nitroglycerin and diltiazem can cause vasodilation, leading to hypotension; thus, monitoring blood pressure is crucial for patient safety.
B. Level of consciousness is incorrect; while important, it is not the primary concern in this context.
C. Daily weights are incorrect; they are more relevant for assessing fluid status over time, not immediate drug effects.
D. Respiratory status is incorrect; while monitoring is important, blood pressure takes precedence due to the risk of hypotension associated with these medications.